Primary vs. Secondary Angle Closure Glaucoma
Angle closure glaucoma is a major cause of blindness worldwide, with a particularly high prevalence in certain populations. This disease has a familial tendency and is associated with increasing age and hyperopia. In angle closure glaucoma, increased intraocular pressure is caused by impaired outflow facility secondary to appositional or synechial closure of the anterior chamber drainage angle . In primary angle closure glaucoma, the underlying mechanism is primarily pupillary block, while in secondary forms there are other underlying causes that either push the iris forward from behind or pull the iris forward to contact trabecular meshwork. Both types of angle closure glaucomas may cause acute dramatic attacks or chronic asymptomatic disease. A thorough history and eye examination are essential in differentiating between primary and secondary forms. This distinction is crucial as the treatment of each form can vary greatly. The mainstays of therapy are medications that lower intraocular pressure and laser peripheral iridotomy for any component of pupillary block. Although angle closure in all its forms is vision threatening, early diagnosis and appropriate management can stabilize disease and minimize vision loss. This review will discuss risk factors, signs and symptoms, diagnostic tests and imaging modalities, pathophysiology, differential diagnosis, and treatment modalities of angle closure glaucoma.
Angle closure glaucoma (ACG) results from appositional or synechial closure of the anterior chamber angle leading to reduction in aqueous outflow facility, IOP elevation, and subsequent damage to the optic nerve with associated visual field loss. There are primary and secondary forms of angle closure glaucoma . In primary angle closure, the mechanism causing disease is primarily pupillary block, being either functional or absolute, while in secondary forms there are other underlying causes.
Primary angle-closure suspect (PACS) or anatomic narrow angle – An eye in which the anterior chamber angle recess has an abnormally narrow angular width. The peripheral iris is located close to, but not touching, the posterior pigmented trabecular meshwork (TM). No PAS are present. IOP, optic nerve, and visual field are normal.
Primary angle closure (PAC) – An eye that has a primary anatomic narrow angle and evidence that trabecular obstruction by the peripheral iris has occurred, such as peripheral anterior synechiae (PAS), elevated IOP, iris whorling or sectoral atrophy, and excessive pigment deposition on the trabecular surface. The eye does not have glaucomatous damage of the optic nerve.
Primary angle closure glaucoma (PACG)-iridotrabecular contact is present in three or more quadrants of the drainage angle in the presence of documented optic nerve damage and visual field loss.
Secondary angle closure is caused by an underlying identifiable pathologic etiology, such as neovascularization or uveitis (see “Differential Diagnosis” section). If angle closure results in elevated IOP that causes glaucomatous optic disc damage, it is referred to as secondary angle closure glaucoma.
Both primary and secondary angle closure can result in acute angle closure attacks and chronic angle closure leading to glaucoma.
See Pathophysiology section below.
A large number of risk factors have been identified:
- Hyperopia 
- Family history of angle closure 
- Advancing age 
- Female gender 
- Asian or Inuit descent   
- Shallow anterior chamber depth 
- Shorter axial length
- Thicker lens
Risk factors for secondary angle closure are related to the underlying diseases that cause it. See Differential Diagnosis section for a list of the various eye diseases that can cause angle closure.
Primary angle closure glaucoma is caused by relative pupillary block in the majority of cases. In pupillary block, aqueous humor encounters increased resistance as it flows from the posterior to anterior chamber through the iris-lens channel. Some degree of relative pupillary block is present in most phakic eyes. The risk of pupillary block is highest with a mid-dilated pupil where there appears to be maximum contact between the iris and the lens. In eyes with angle closure, other factors exacerbate the block, such as the front lens surface being anterior to the plane of iris insertion into the ciliary body base. The increased pressure gradient across the pupil causes the peripheral iris to bow forward and cover some or all of the filtering portion of the trabecular meshwork, resulting in appositional angle closure. Peripheral anterior synechiae form after prolonged or repeated contacts of the peripheral iris with TM. Another mechanism thought to be important in primary angle closure is iris angle crowding, which is caused by a thickened peripheral iris filling the space between the TM and angle recess under dark conditions. 
Eyes that experience angle closure are not only anatomically different than normals — they have shorter axial lengths, shallower anterior chambers, thicker and relatively anteriorly positioned lenses, and flatter corneas — but they are also physiologically different. Thicker irides may increase the posterior to anterior pressure differential. Dynamic factors in angle closure eyes that can contribute to increased pupillary block are the tendency to retain more iris volume after dilation and choroidal expansion causing forward lens movement. As imaging modalities, such as ultrasound biomicroscopy and anterior segment optical coherence tomography improve, these dynamic factors will be better studied and understood.
A less common cause of primary angle closure is anterior non-pupillary block. This is observed in eyes in which angle closure progresses despite a patent iridotomy, for example, as seen in plateau iris. Plateau iris configuration is characterized by a normal central anterior chamber depth, flat iris profile, and crowding of the angle by the iris base. There is a forward displacement of the iris base by anteriorly located ciliary processes that can lead to subsequent angle closure. Plateau iris syndrome occurs when an eye with plateau iris configuration develops a closed angle. Prominent last iris roll is another mechanism of anterior nonpupillary block in which a very thick iris with prominent peripheral circumferential folds becomes more pronounced and contacts trabecular meshwork with dilation.
Secondary angle closure glaucoma is caused by a myriad of other eye diseases (see Differential Diagnosis section). There are several secondary causes of angle closure that involve relative and absolute pupillary block. In phacomorphic glaucoma, the mass effect of a thickened or intumescent cataract pushes the iris forward and causes pathological angle narrowing. Forward displacement of the lens in ectopia lentis or microspherophakia can also push the iris forward and shallow the angle. Absolute pupillary block occurs when there is no movement of aqueous through the pupil because of 360o posterior synechiae between the iris and a crystalline lens, an intraocular lens, capsular remnants, or the vitreous face. In secondary angle closure glaucoma without pupillary block, angle closure is due to either a.) contraction of an inflammatory, hemorrhagic, or vascular membrane in the angle leading to PAS, or b.) forward displacement of the lens-iris diaphragm, often associated with ciliary body swelling and anterior rotation.
|Mechanisms that push the iris forward from behind|
|Mechanisms that pull the iris forward into contact with the trabecular meshwork|
Given the high prevalence and morbidity of angle closure glaucoma in many countries, there is a need for quick, inexpensive screening methods that do not require highly skilled operators.
Oblique flashlight test uses a penlight that is held next to the temporal side of an eye with the beam of light parallel to the iris and shining across the anterior chamber. If there is a shadow projected onto the nasal iris, the angle is narrow because the iris is bowed forward and blocking the path of light. If there is no shadow, the anterior chamber angle is considered open. Because of variability in flashlight illumination and subjectivity in assessment of the test result, however, this test has a relatively low specificity.
The Van Herick method uses a narrow slit beam at 60o onto the cornea just anterior to the limbus to evaluate the anterior chamber depth. If the distance from the anterior iris surface to the posterior corneal surface is less than one-fourth the corneal thickness, the angle may be narrow and should undergo gonioscopy. Modification of this method by creating additional grades, called the limbal chamber depth test, outperformed central anterior chamber depth (as measured by optical pachymetry and ultrasound) and autorefraction as a screening tool for the detection of occludable drainage angles identified by gonioscopy.
Laser peripheral iridotomy for narrow angles
The goal of screening for narrow angles is to identify patients at risk of developing angle closure and to treat prophylactically with a laser peripheral iridotomy (LPI). Patients with narrow but open angles should be followed for IOP elevation, progressive angle narrowing, and development of PAS. There is no evidence that iridotomy is indicated for narrow but open angles with normal IOP; however, LPI is fairly safe and can prevent a potentially vision-threatening outcome so the risks and benefits must be carefully considered in each case and discussed with the patient in details.
|Indications for laser peripheral ridotomy|
Diagnosis of both primary and secondary angle closure glaucoma is based on history and eye exam. Gonioscopy is the gold standard for evaluating the anterior chamber angle, but imaging modalities assist in quantifying and objectifying angle characteristics. To distinguish between primary and secondary causes, the clinician must actively look for signs and symptoms of possible secondary causes and rule each out before the patient can be diagnosed with primary angle closure glaucoma .
- History of present illness – typical signs and symptoms of acute or subacute angle closure attacks (see Signs and Symptoms sections) and if patient was upset or in the dark when symptoms started
- Past ocular history
- Trauma – can cause zonular weakness or dehiscence allowing lens to displace anteriorly
- Incisional or laser surgery – can cause anterior chamber inflammation or predispose to epithelial/fibrous ingrowth; may also lead to aqueous misdirection (e.g. after LPI) or ciliary body engorgement (e.g. after extensive panretinal photocoagulation).
- History of prior retinal vein occlusion – can cause angle neovascularization or ciliary body engorgement rotating lens forward
- Past medical history – history of diabetes or carotid stenosis disease that can cause angle neovascularization
- Medications – use of systemic medications, such as sulfonamide, topiramate, and phenothizaines, that may cause ciliary body engorgement or suprachoroidal effusion; use of medications to treat allergy, bladder dysfunction, or depression; use of anticholinergics or sympathomimetics that can dilate pupil
- Family history of acute angle glaucoma
- Refractive status – hyperopic eyes tend to have shallower anterior chamber angles which places them at risk for angle closure
- Pupil size and reactivity
- Slit lamp exam
- Conjunctiva – injection
- Cornea – clarity, presence of edema, evidence of surgical or traumatic wounds
- Anterior chamber – central and peripheral depth, inflammation
- Iris – areas of atrophy, mass, neovascularization, or posterior synechiae
- Lens – thickness, phacodonesis, subluxation, glaucomflecken (necrosis of anterior lens capsule; may indicate previous attacks)
- Intraocular pressure measurement, preferably with applanation prior to gonioscopy
- Gonioscopy of both eyes with indentation to evaluate for appositional versus synechial angle closure
- Evaluation of fundus and optic nerve – dilation is often not advisable in primary angle closure attack until an iridotomy has been performed and/or the acute attack has resolved as dilation can exacerbate the condition. In contrast, dilation may be permissible as the appropriate treatment in certain forms of secondary angle closure. The fundus should be examined for underlying causes leading to the angle closure.
Signs of a primary anatomic narrow angle on slit lamp exam can be subtle and include a shallow anterior chamber and an anteriorly bowed iris.
Both primary and secondary forms of angle closure can cause acute angle closure attacks. The intraocular pressure usually exceeds 40 mmHg and may rise to as high as 80 mmHg. The conjunctiva is significantly injected. The cornea develops stromal and microcystic edema in response to the acute rise in eye pressure and decompensation of the endothelial pump mechanism. Iris sphincter ischemia leads to a fixed, mid-dilated pupil. Sectoral iris atrophy may occur, releasing pigment into the anterior chamber that dusts the corneal endothelium and anterior lens capsule. The overall anterior chamber is shallow. The center is usually formed, but the mid-peripheral iris bows forward and may touch the peripheral cornea. Often there is anterior chamber inflammation. The fundus is typically difficult to examine because of corneal edema. If visualized, the optic nerve head may be hyperemic and edematous. The angle is often difficult to examine with gonioscopy because of corneal edema, but if visualized, reveals contact of the peripheral iris with cornea.
In the aftermath of an acute attack, pupillary distortion may result if there is permanent sphincter damage and/or iris atrophy. Anterior lens capsule opacities, known as glaukomflecken, may result from damage to the anterior lens epithelium from high intraocular pressure. The angle may have permanent synechiae formation. Intraocular pressure may be low if the ciliary body is so ischemic that aqueous humor production is compromised. As the ciliary body recovers, normal aqueous humor production resumes and the intraocular pressure rises.
ACG exhibits signs of optic neuropathy in the typical glaucomatous pattern with increased cupping of the optic nerve and retinal nerve fiber layer dropout.
|Summary of Clinical Findings in Various Types of Secondary Angle Closure Glaucoma|
Patients with anatomic narrow angles without acute angle closure are typically asymptomatic in both the primary and secondary forms. Similarly, primary and secondary chronic angle closure patients often experience no symptoms unless they develop end-stage glaucoma, in which case they may complain of decreased vision or reduced peripheral vision.
Acute angle closure, on the other hand, usually presents with dramatic symptoms from the quick rise in intraocular pressure. Patients complain of blurred vision, rainbows, halos around lights, or even transient loss of vision. They often have intense pain that may be localized to the eye, may follow the trigeminal distribution, or may be described as diffuse discomfort. Nausea and vomiting are common.
Subacute or intermittent angle closure attacks are brief episodes of angle closure that resolve spontaneously. Patients experience the above symptoms of acute angle closure, but on a milder scale. They will typically experience some blurring of the vision or halos with mild to moderate eye pain, brow ache, or headache. These attacks are often resolved by entering a well lit room which may cause miosis or sleep as sleep-induced miosis ameliorates the lesser degree of pupillary block in these patients.
The key to diagnosis of anatomic narrow angle or angle closure is gonioscopy, which is still the gold standard method of angle evaluation. The ideal way to perform gonioscopy is in a dark room using a small rectangle of light only as bright as necessary to view the angle structures, as light can open an appositionally closed angle in about one-third of cases.  Dynamic or compression or indentation gonioscopy is essential to differentiate appositional closure from synechial closure. Gentle pressure on the cornea with the goniolens pushes back the iris and reveals whether the angle can be opened any further; if not, synechial closure is present. This maneuver can also help break acute attacks by forcing fluid into the periphery and opening areas of appositional closure.
Occludable angles are typically described as eyes in which the posterior, usually pigmented, trabecular meshwork is seen for less than 90° of the angle circumference or if the angle width is less than 20°.
|Angle Grading and Classification Systems|
|A. Scheie system (R)|
0 – entire angle visible with wide ciliary body band
Pigmentation graded 0 (no pigmentation) to 4 (heavily pigmented)
|B. Shaffer system (R)|
0 – closed or slit
|C. Spaeth system (R)|
Level of iris insertion:
Angle width – estimated in degrees from line tangential to the trabecular meshwork to line tangential to the iris surface one third of the way from the periphery (ranges from 0 - 40 degrees)
|Curvature of iris:|
r – regular configuration, no significant forward or backward arching of iris
|Pigmentation: 0 (no pigment) to 4 (heavy pigmentation)|
|Change in angle configuration after indentation performed described by putting the original insertion in parenthesis, followed by the insertion after indentation. For example, if indentation shows that the insertion is actually a D when it originally appeared to be a C, it is indicated as a (C)D.|
Photos Courtesy of Sarwat Salim, MD, University of Tennessee
Various provocative tests have been developed in an attempt to separate out patients who may be at higher risk of angle closure. In these tests, different maneuvers are used in an attempt to induce pupillary block, and then the pressure is rechecked and the angle is examined for narrowing. A test is considered positive if the IOP increases by 8 or more mmHg. In the dark room test, patients are placed in a dark room for 1-2 hours to dilate the pupil and increase resistance at the lens-iris channel.
The prone test involves placing the patient in the prone position for 1-2 hours without sleeping to anteriorly displace the lens and increase pupillary block. These tests have not been found to be very predictive of angle closure. Combining anterior chamber imaging (e.g. ultrasound biomicroscopy) with provocative testing assists in detecting apposition and allows measurement of various parameters of the angle,  but their ability to predict future angle closure is not well established.
Pharmacologic provocative tests using mydriatic eye drops to increase pupillary block via pupil dilation have fallen out of favor as they carry a significant risk of angle closure in and of themselves.
To supplement information obtained through gonioscopy, there are several anterior segment imaging devices available that provide detailed images of structures and quantitative measurements. They are useful in primary angle closure but can also help detect secondary cases of angle closure, such as ciliary body masses or anterior rotation. At this time, there are no widely agreed upon quantitative measurement cutoffs obtained from these devices that distinguish a narrow angle from an open one.
Ultrasound biomicroscopy (UBM)
This high-frequency B scan ultrasound provides high-resolution cross-sectional images of the anterior segment of the eye to the anterior vitreous. Because it uses sound, it can pass through opaque structures to visualize structures hidden from direct clinical examination, such as the ciliary body. It is particularly helpful for evaluating plateau iris and other ciliary body pathology. The disadvantages of UBM include: requirement of a water bath immersion, specialized equipment, and a skilled technician to operate; it is also relatively costly and time consuming.
Anterior segment OCT (AS-OCT)
This modality uses a diode light source instead of sound to produce highly detailed images of the cornea, angle region, and anterior ciliary body similar to those seen with UBM. Compared to UBM, AS-OCT is unable to image structures posterior to the iris plane well because of posterior pigmented iris shadowing and scleral light scattering. The advantages of AS-OCT are that it is a noncontact exam: the patient can be imaged in an upright position avoiding positional lens changes, and all four quadrants can be scanned at once.
Digital images of the anterior chamber angle can be obtained using a Scheimpflug camera. Rotating versions of the camera provide three-dimensional photos that can be analyzed by computer software to measure specific parameters of the angle. The camera has an easy-to-use slit lamp type configuration but is expensive and requires special equipment. It cannot image the ciliary processes or body behind the iris.
Optic nerve assessment and imaging, retinal nerve fiber layer analysis, and visual field testing should be preformed to assess for signs of glaucomatous optic neuropathy in any patient with angle narrowing or angle closure glaucoma.
The main entities to distinguish are primary angle closure versus secondary causes of angle closure because treatment may differ depending on the etiology. Primary disease tends to be bilateral, while disease caused by a secondary etiology may be unilateral or bilateral. Please refer to the previous tables for various causes of secondary angle closure glaucoma.
The overall goals for management are to reverse or prevent the angle closure process, control intraocular pressure elevation, and prevent damage to the optic nerve. Some primary and secondary forms of angle closure may be treated similarly, while others require very different treatment approaches based on their underlying pathophysiology. IOP is lowered with glaucoma medications. Iridotomy is an essential part of treatment in PAC, but may not be indicated in some forms of secondary angle closure glaucoma. Trabeculectomy and tube shunts may also not be indicated for certain secondary forms of angle closure glaucoma.
Acute angle closure glaucoma
The role of medical therapy in acute angle closure attacks is to lower IOP, reduce pain, and clear corneal edema in preparation for iridotomy. The medications below can be used, provided the patient has no condition contraindicating them:
- Beta blockers
- Selective alpha agonists
- Carbonic anhydrase inhibitors
- Miotics (e.g., pilocarpine 2%) may help break an early angle-closure attack, but may be ineffective if the iris is already ischemic. High-concentration miotics (e.g., pilocarpine 4%) should be avoided because of the potential for forward displacement iris-lens diaphragm.
- Prostaglandin analogues – unreliable effect in acute attack because of slow onset of action
- Hyperosmolar agent (e.g. 5% sodium chloride) – assists in clearing corneal edema
- Prednisolone 1% - decreases inflammation
- Carbonic anhydrase inhibitors – oral acetazolamide’s maximum IOP reduction is reached in 2-4 hours and lasts for 6-8 hours. Intravenous acetazolamide drops the IOP within 2 minutes with a peak effect noted by 10-15 minutes. In acute situations, a single dose of 500 mg acetazolamide should be given orally if the patient is not vomiting. Regular acetazolamide is preferred over the sustained-release sequel form because of quicker onset of action. If the patient is vomiting, acetazolamide can be given intravenously.
- Osmotic agents
- Mannitol can decrease the IOP 30 mm Hg or more within 30 minutes of administration. The recommended intravenous dose is 0.5-1.5 g/kg body weight as a 15% or 20% solution, delivered at 3 to 5 mL/minute. Frail patients with cardiac or conditions may develop circulatory overload, pulmonary edema, congestive heart failure, and electrolyte imbalance. A rapid reduction in cerebral volume may result in subdural hematomas from vein rupture between the sagittal sinus and cortical surface. Therefore, patients receiving IV mannitol should be monitored in a hospital setting.
- Oral osmotic agents:
- Glycerin: 1 to 1.5 g/kg body weight of a 50% solution. Onset of pressure reduction is typically 10 to 30 minutes. Avoid in diabetics because the increased caloric load can cause ketoacidosis.
- Isosorbide is commercially available as a 45% (45 g/100 mL) solution (Ismotic; Alcon Surgical). The recommended dose is 1 to 1.5 g/kg body weight. Its effect is similar to glycerin’s but is safe for use in diabetics because it is not metabolized.
- Although less common, oral agents can also cause subdural hematomas. Headache and gastrointestinal upset are common adverse reactions.
Paracentesis Can be perfomed in an acute setting. Technically, it can be difficult to perform on a phakic eye in pain with a shallow chamber, and there is a risk of permanent damage to the cornea, lens, and iris. Devastating complications such as endophthalmitis and choroidal hemorrhage from a rapid pressure drop may occur. Also the effects are typically short-term, because, as the ciliary body begins to form aqueous again, the IOP will inevitably rise. This procedure can be used in cases of extreme IOP elevation to “buy time” until medications take effect or iridotomy can be performed.
Laser Iridotomy Should be performed as soon as possible in the affected eye and in the contralteral eye to avoid an attack of acute angle closure glaucoma in the future.
Chronic angle closure glaucoma
Very few studies exist to address medical therapy in chronic angle closure glaucoma after laser iridotomy. In cases where elevated IOP becomes an issue, aqueous suppressants are helpful in reducing IOP. Prostaglandin analogues have been shown to be effective in lowering IOP, even in angles that are partially closed.  Evidence is not conclusive, however, regarding their effectiveness in cases of 360° degrees of synechial closure. The role of PI and other surgical interventions are described below.
See Primary prevention section for information regarding prophylactic LPI for narrow angles.
Acute Angle Closure and Fellow Eyes
In angle closure secondary to pupillary block, an iridotomy is the definitive treatment. Laser peripheral iridotomy (LPI) is considered an effective and safe treatment. It often breaks an attack of acute angle closure and can prevent future attacks. An incisional iridectomy may be necessary in cases of cloudy corneas, flat anterior chamber, poor patient cooperation at the laser, or inability to substantially lower the IOP with medications after a failed LPI attempt.
The fellow eyes of patients that have undergone primary acute angle-closure are generally at significant risk for an acute attack and should receive an iridotomy.  An untreated fellow eye has a 40% to 50% chance of developing an acute PAC attack over the next 5 to 10 years.   Chronic miotic therapy is not an acceptable alternative, as 50% of contralateral eyes of individuals suffering acute PAC developed acute attaks when treated with pilocarpine alone. This is in contrast to the 1.8% of patients treated with prophylactic incisional iridectomy who developed an attack during this same time period.
Chronic Angle Closure and Angle Closure Glaucoma
LPI relieves the pupillary block component in chronic disease and may halt the progression of synechial closure and progressive IOP elevation. Its ability to control IOP, however, may not be long-lasting, especially in eyes where glaucomatous optic neuropathy has already developed. Additional medications or surgical treatment is often necessary. In cases where LPI does successfully lower IOP, eyes still need to be monitored routinely as IOP can increase months or years after the procedure.
Persistent or progressive rise in IOP after LPI
- Damage to trabecular meshwork and/or formation of PAS has occurred when iridocorneal apposition present
- Pupillary block may recur if iridotomy becomes occluded
- Factors other than pupillary block causing angle closure may have gone unrecognized until after the LPI (e.g. plateau iris syndrome)
- Angle closure may have been superimposed on pre-exisitng open angle glaucoma or another eye condition causing IOP elevation, such as pseudoexfolation
- There may be co-existing chronic open angle glaucoma
Complications of LPI
The most common complications of LPI are transient bleeding at site of treatment, hyphema, postoperative pressure spike, and anterior chamber inflammation. Occasionally, patients may complain of a seeing a double image if the lid does not cover the iridotomy site. More severe but rare complications include aqueous misdirection and injury to the cornea, lens, or retina.
In laser iridoplasty, contraction burns of long duration, low power, and large spot size are placed on the peripheral iris to contract the iris stroma and physically pull the iris from the drainage angle in an attempt to open the angle. In acute angle closure, iridoplasty has been found effective and safe in short-term lowering of IOP.  It can be used in cases that are medically unresponsive, in which systemic carbonic anhydrase inhibitors must be avoided, when immediate iridotomy is not possible, or rarely when the attack continues despite a successful LPI. It is the procedure of choice for plateau iris syndrome when the angle fails to open and IOP remains elevated despite a patent peripheral iridotomy. In chronic cases of angle closure, iridoplasty may slightly decrease the formation of PAS.
It is important to note that iridoplasty does not eliminate pupillary block, so iridotomy remains necessary if pupillary block is the mechanism of angle closure.    Potential complications include IOP spike, iris atrophy from destruction of iris vessels, corneal burns, marked anterior chamber inflammation, and corneal endothelial damage.
In PAC, since the lens is a key player in development of relative pupillary block, it makes sense that cataract extraction can lower IOP in both acute and chronic angle closure. Removal of the lens from an eye with a crowded anterior chamber opens the angle and may prevent or reduce PAS formation. In one study, early phacoemulsification was found to be better than LPI at preventing IOP rise after an acute angle closure event was controlled medically. Cataract extraction in the setting of an acute angle-closure attack, however, is technically difficult. The eye is inflamed with significant corneal edema, a shallow anterior chamber, an atrophic and atonic iris that is difficult to dilate, and possible zonular weakness. It may be more prudent to control the acute attack with medications and LPI first and then wait to perform surgery when the eye has recovered and is less inflamed.
In the chronic phase when patent laser iridotomy and medical treatment have failed to adequately control IOP, lens extraction many months after the initial attack has been found to reduce IOP and reduce the need for IOP medications.   Cataract extraction can be combined with goniosynechialysis to further improve IOP control in the short term. Methods of goniosynechialysis include breaking synechiae with a heavy viscoelastic (viscogonioplasty), forceps, or a cyclodialysis spatula.
In lens-induced ACG, which includes phacomorphic glaucoma and angle closure due to forward subluxation of the lens, the definitive treatment is lensectomy. Acute attacks can be first controlled with medical therapy and/or LPI with lens extraction performed when the eye is quiet.
Filtration surgery has been performed for both acute and chronic angle closure glaucoma. The indications to perform filtration surgery in PACG are similar to those for surgery in POAG. In chronic cases, surgery is considered if the optic neuropathy is progressing and IOP is at a level believed to be contributing to the progression. Reasons for performing filtration surgery in the setting of an acute closure attack include medical unresponsiveness, lack of laser availability, or signs of glaucomatous optic neuropathy already present. The same techniques of filtration surgery are used as in POAG, although some surgeons advocate tighter suturing of the trabeculectomy flap to avoid low IOP in the immediate postoperative period. A low IOP may contribute to further anterior chamber shallowing, which may lead to a higher rate of malignant glaucoma postoperatively.   
Whether to perform filtration surgery versus a tube shunt procedure for secondary angle closure glaucoma depends on the underlying etiology. In most cases, dealing with the underlying pathology (e.g. stopping topiramate in drug-induced glaucoma, removing the lens in lens-induced glaucoma) will slow or stop the progression of disease. If medical therapy is not sufficient to control IOP, even when the primary pathology has been addressed, glaucoma surgery may be necessary and filtration surgery may be appropriate. Conditions such as neovascular glaucoma and ICE, however, tend to do better with glaucoma drainage implants. (see below). It has been proposed that combined phacotrabeculectomy may be more effective at controlling IOP than cataract extraction alone. Recent study results have been mixed, with some showing phacoemulsification as being superior for deepening the chamber, the two procedures being equal in terms of IOP control, and combined procedures being superior for IOP control. Of note, one randomized control trial found that patients who undergo combined procedures have more postoperative complications and progression of their optic neuropathy compared to the phacoemulsification alone group, so the risks and benefits of each procedure need to be carefully considered in each case until more definitive evidence is available.
Glaucoma drainage implants
A limited number of studies look at the use of tube shunt devices in PACG. PACG eyes are often placed into the category of refractory glaucoma along with other types of glaucoma and thus are not separately evaluated. Based on the limited data available in these studies, tube implants appear effective in controlling IOP in PACG. Drainage implants are considered more effective than filtering procedures in neovascular glaucoma and ICE syndrome because, in these diseases, a fibrovascular membrane often grows over the sclerostomy site causing bleb failure.
Other surgical procedures
- May be required depending on the etiology of the underlying disease.
- Aqueous misdirection: Nd:YAG laser can be used to disrupt the anterior vitreous in aphakic and pseudophakic eyes. If that is not successful, definitive surgical treatment in the form of vitrectromy with anterior hyaloid disruption combined with an anterior chamber deepening procedure may be indicated.
- Epithelial and/or fibrous downgrowth: radical surgery to remove the intraocular membrane and affected tissues may be necessary.
- Angle closure that develops after retina surgery may require removing or loosening encircling bands, opening up iridectomy sites, or removing silicone oil.
Surgical follow up
Patients typically need to be watched closely in the immediate postoperative period, sometimes weekly for several months. Once IOP control is achieved and the eye is stabilized, follow up can follow the schedule of routine PACG patients.
Complications of acute angle attacks are the result of a rapid, extreme rise in IOP. Possible sequelae include corneal decompensation, cataractous lens changes, iris ischemia resulting in atrophy and distortion, ciliary body shutdown with resultant hypotony, central retinal vein occlusion, optic nerve ischemia, and acute permanent vision loss.
Complications of chronic disease include all the same ones that can be seen in acute disease. The difference in chronic disease is that these conditions develop in a more insidious fashion over a longer period of time. These patients typically have asymptomatic progression of glaucomatous optic neuropathy with corresponding visual field defects developing over time.
Primary angle closure suspects
The overall likelihood of an individual with a narrow angle developing acute angle closure in the United States is less than 10%. A prospective multicenter study, however, found that patients judged to be at risk for developing ACG by experienced ophthalmologists through careful slit lamp exam and gonioscopy had a 30% risk of developing angle closure within 5 years when no prophylactic intervention was performed. See “Primary Prevention” for recommendations regarding prophylactic LPI in PACS.
In contrast, fellow eyes in which the other eye has already suffered an acute angle closure attack have a much worse prognosis without prophylactic treatment. An untreated fellow eye has a 40% to 50% chance of developing an acute PAC attack over the next 5 to 10 years. An iridectomy or iridotomy virtually eliminates the risk. The long-term fate (4–6 years) in terms of IOP and glaucomatous optic neuropathy is good for most fellow eyes after LPI with the majority not requiring any additional glaucoma treatment and retaining good vision.
Acute angle closure
In an eye suffering an acute angle-closure attack, the long-term outcomes vary depending on ethnicity (which may be a reflection of mechanism of angle closure), duration of attack, and severity of attack in terms of whether or not it can be aborted by medical treatment alone. If promptly treated, most (60%–75%) symptomatic episodes of angle closure recover without visual field or optic disc damage in the short term.  Six months post-attack, one study reported 38% of eyes to have visual field loss secondary to nerve fiber bundle loss. In another study, 2 - 16 weeks after an attack, changes were noted in optic disk morphology, with preferential loss in the superotemporal and inferotemporal areas.
The longer the duration of an attack and the more difficult to manage, the worse the outcome for the eye, regardless of the initial IOP measurement.   Patients with a 24 to 72 hour delay in presentation had a relative risk of 2.78 for developing chronic glaucoma, whereas those requiring laser iridotomy to control IOP or a trabeculectomy had relative risks of 3.63 and 4.83, respectively. In Singapore, risk of visual field loss was significant if the duration of symptoms was longer than 7 days.
Even despite successful termination of an acute attack by surgical iridectomy, late IOP increase is reported in 19% to 24% of cases.  There may be ethnic differences in the rate of IOP control by LPI alone. A greater extent of PAS, a high presenting IOP, and a larger cup to disc ratio have been reported as predictors of poor pressure control following iridotomy.  A significant portion of patients go on to develop PACG and require further medical or surgical intervention in an attempt to control their disease. Unfortunately, up to 20% these patients deteriorate to lose significant vision and are classified as blind in that eye.
Chronic angle closure glaucoma
Asymptomatic angle-closure patients present with more severe visual field defects than symptomatic patients.  In one study which examined visual field loss on presentation, 52.8% of asymptomatic PACG had end stage visual field loss by Advanced Glaucoma Intervention Study criteria compared to only 17.5% of symptomatic PAC cases. Although presenting IOP was considerably higher in the symptomatic group, the level of IOP was not found to be a significant predictor for visual field outcome. It is likely that the duration of elevated IOP has a major influence in causing optic nerve damage in PACG, possibly more so than the level of IOP. Once glaucomatous optic neuropathy has developed, almost all cases will require further treatment to control IOP (94%–100%). Closer monitoring of IOP is recommended in CACG compared to POAG, despite the efficacy of medical therapy. Chronic angle-closure glaucoma tends to progress more quickly and fail medical therapy sooner than POAG.  With aggressive management, however, chronic ACG patients can maintain stable fields and long-term IOP control.
Secondary Angle Closure
The prognosis for secondary angle closure patients depends on the underlying etiology. Early recognition of the underlying pathology and timely directed treatment helps to improve outcomes.
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